Abstract
Integrative Medicine, specifically acupuncture and Traditional Chinese Medicine (TCM) is gaining popularity within western medical systems and hospitals in the United States. This article reviews the challenges faced and the progress made through the eyes of two acupuncturists practicing within such a system. In both the Austin/Round Rock and Dallas regions of Baylor Scott & White Health, patients have access to Integrative Medicine along with the other clinical specialties. The team strives to fully integrate within the modern healthcare system as opposed to existing as a mere alternative to standardized care. The members of the department actively educate our colleagues, patients, and community as we work toward mainstreaming integrative medicine.
While Integrative Medicine at Baylor Scott & White Health includes several modalities, this article focuses on acupuncture and TCM specifically.
Background
Baylor Scott & White Health is the largest not-for-profit healthcare system in the state of Texas and one of the largest in the United States. The organization comprises 48 hospitals, 164 primary care clinics, and 503 specialty care clinics spread throughout north and central Texas.1 Nearly every physician specialty is covered including internal medicine, obstetrics and gynecology, neurology and neurosurgery, orthopedics, sports medicine, pain management, oncology, palliative care, and mental health. Baylor Scott & White Health has a rich history of providing the highest quality care as an integrated delivery system and is at the forefront of effective, evidence-based, innovative medicine in Texas.
Introduction
Integrated delivery, or providing primary care and specialty services in one united system comprised of both clinics and hospitals, ensures the best possibility of comprehensive, collaborative care. The system utilizes a shared electronic medical record (EMR); if a patient sees any specialist at any facility, those records will carry over to all future visits within Baylor Scott & White. This not only streamlines a patient’s records, but it also allows for enhanced practice capabilities for clinicians. It enables the provider to access her patient’s chart containing all pertinent historical data prior to seeing the patient, and encourages more collaboration between providers and specialists whose patient panels may intersect. Ultimately, this reduces repetition which in turn promotes efficiency and slashes costs system-wide.
The system’s design is inherently welcoming for integrative medicine. Prior to the program’s inception, discussion began among physicians and administrators regarding the possibility of integrating complementary therapies into the system. The general consensus was that patients were interested in these treatment options and providers wanted to suggest these modalities, but lacked reputable referral sources. An advantage to an integrated system is how easy it is to become familiar with other providers and their practice styles. It creates a level of comfort when referring internally. Conversely, it may cause some hesitation when referring a patient to an unknown provider, especially if it is within a specialty with which they may be unfamiliar. The results of a provider survey in the Austin/Round Rock region showed that physicians and advanced practice professionals were most interested in adding massage therapy and acupuncture to the system’s offerings. Thus, the integrative medicine department was born. It is important to note that the name ‘integrative medicine’ is more appropriate than ‘alternative medicine.’ This emphasizes that these approaches should be combined with western medicine to create the most successful modern healthcare model.
Department Structure
At its beginning in 2015, the department consisted of only one acupuncturist and one massage therapist based out of two small primary care clinics in Austin and nearby Round Rock. The program has since grown, and now offers services in seven primary care and multispecialty clinics in the greater Austin and Dallas regions. The clinical team is comprised of five acupuncturists, four massage therapists, and one yoga instructor. One of our practicing acupuncturists supervises the department, and we have a director for program oversight. Additionally, our team includes seven integrative and functional medicine physicians in various specialties. As we continue to spread throughout Texas, we have made a concerted effort to maintain our team mentality to enhance care as well as our own quality of life as providers. Our Dallas and Austin acupuncturists are separated by over 200 miles, yet we maintain communication through virtual meetings, joint projects, and regular case consultations. Ultimately, we believe it is the patients that benefit most from our highly collaborative, non-competitive mindset, because each acupuncturist is able to maintain his or her unique approach while benefiting from the diverse clinical backgrounds within the team.
Provider and Community Outreach
A survey published by the American Hospital Association indicates that 42% of hospitals in the United States now offer some type of complementary and integrative treatment.2 Massage therapy is the most common modality offered, while acupuncture falls second. This data appeals to administrators and speaks to acupuncture’s increasingly indispensable role in modern healthcare. A challenge with instituting a new service line in such an expansive system is creating awareness of the department’s existence. To do this, we held almost 50 “lunch and learns” with our internal providers within our first three months. These informal discussions made it apparent to us that there are gaps in understanding regarding TCM, and we were faced with the task of bridging those gaps.
Data from Advances in Medical Education and Practice indicates that 66 medical schools in the United States offer courses in Complementary and Integrative Medicine (CIM) as of 2015.3 Though medical providers may have had exposure to CIM, their information may be preliminary, outdated, or even invalid. We are thus tasked with correcting misinformation and demonstrating both the efficacy and relevancy of acupuncture within the established system. In order to do this, we have engaged in outreach both within and outside of our system. Our team has presented case studies, led informal round tables, delivered formal demonstrations, and launched collaborative events. Externally, our outreach includes lectures both on and off campus, acupressure treatments at health fairs and community events, presentations at Rotary clubs and cancer survivor groups, and free classes at the local libraries, community centers, and health clubs. Combined, our team has participated in over 250 outreach events over the past four years. By engaging in these activities, we are actively educating our colleagues, patients, and community as we work toward mainstreaming integrative medicine.
Conditions Treated
Because multiple specialties refer to our department, we treat a varied and diverse patient population. As a result of consistent outcomes and positive provider relationships, we have created strong collaborative approaches with a few departments in particular. Our most frequent referrals come from: obstetrics and gynecology for fertility, labor induction, and dysmenorrhea; primary care for peripheral neuropathy, stress and depression, and digestive disorders; pain management for chronic pain; oncology for chemotherapy side-effects; and neurology for migraines and headaches. We benefit tremendously from a large team of open-minded, progressive physicians across all spectrums of medicine, and our provider colleagues are currently our strongest referral sources. Though a referral is not required for treatment, roughly 50% of our patient panel originates from internal physician and APP referrals. The remaining half come from word-of-mouth referrals from our established patients, online searches, insurance carriers’ in-network lists, and from outreach events.
Integration
Our team works alongside physicians, physician assistants, nurse practitioners, chiropractors, and support staff. By sharing space, we create an environment of interdependence which allows us to combine our strengths and methodologies. We try to make ourselves readily available for on-the-spot consults in between patients. We have been given the flexibility to try things we believe have a place in the future of medicine. For example, our obstetrics team began presenting acupuncture for labor pains as an option to patients desiring a natural childbirth after a casual conversation between our departments regarding Chinese medicine and acute pain. We are incredibly fortunate to work with such a talented group of physicians to whom we can refer when the patient needs different care than we can provide. For some, we are the patient’s first exposure to Baylor Scott & White, and they may need help identifying a primary care provider. Others may present with some type of red flag that needs urgent attention and we can easily refer out or transfer the patient to the emergency department.
Though invaluable, true integration takes more than physician support. Our EMR platform (Epic) was also enhanced to accommodate integrative medicine. The Epic team developed the functionality of integrative medicine scheduling because we are the only department that overlaps appointments. Analysts worked with us in multiple phases to create charting templates that fit our unique needs. As we grow, we continue to add unusual requests, like the ability to schedule one appointment with both an acupuncturist and massage therapist who will treat the patient simultaneously. The integrative medicine department’s presence has expanded into other areas of our system as well. Some Baylor Scott & White pharmacies carry Sea-bands© and herbal teas for nausea, Chinese herbal analgesics for pain, and recipes and educational books recommended by our functional medicine physicians. Our aim is to leave our mark, no matter how small, throughout each of our hospitals and clinics in an effort to truly establish acupuncture as a major player in the conventional healthcare model.
Avoiding Limitations
One barrier to blending Chinese Medicine and western medicine is the significant differences in terminology. TCM existed long before MRIs and CBCs, so we use terms like “qi,” “xue,” “mai” and “yin and yang,” in diagnoses. We assess the patient’s many pulses, the look of their tongue, skin, eyes, ears, and the sound of their voice. Acupuncturists have complex palpation approaches that go far beyond identifying trigger points. These differences sometimes mislead people to think that TCM is purely metaphysical and not rooted in science, but that is not the case; all of this can be translated to western medical explanations. An acupuncturist who is the right fit for this type of setting will not only excel as a translator, but will enjoy bridging the two medicines. Being able to interpret imaging and lab tests and translate that back to Chinese medicine is equally important. That said, only using terminology that is foreign to the origins of acupuncture can lead to an over-simplification of the medicine, disrupting its true identity. Because of that, it is important to maintain the integrity of the medicine by continuing to use its true etiological and pathological terms. Acupuncturists working within integrated systems should not feel pressured to avoid the roots of the medicine and conversely, we should encourage physician curiosity and questioning.
A potential downside to practicing acupuncture and Chinese medicine within a western clinical setting is the risk of reducing the scope of practice. Some TCM providers practicing within hospital systems are limited to the use of acupuncture only (potentially excluding moxibustion, cupping, gua sha, infrared, bloodletting, food therapy, and herbal formulations). Our opinion is that these limitations are unnecessary and negatively impact clinical outcomes, which is unfair to both patient and practitioner. As such, it is important to allow acupuncturists to incorporate all aspects of their training within clinical practice. At Baylor Scott & White, we utilize our full scope, including the recommendation of patent and customized herbal formulations. Scope of practice limitations are likely the result of fearing what is not understood combined with inefficient communication. It took a forward-thinking leadership team to agree that practicing within full scope is logical and best for patients. After that, we worked with a dedicated and open-minded quality control department to ensure our already high standards of Clean Needle Technique met the stringent safety standards of the hospital. Of course, it is important to note that scopes of practice vary from state to state, and providers are responsible for practicing within those statutes.
Insurance Coverage
One accomplishment that reflects systemic integration relates to our employee health insurance plan. Before the Integrative Medicine department was developed, acupuncture was not a covered benefit for BSW employees. In the first year of the department’s existence, the plan began to include acupuncture but limited coverage to only six qualifying diagnoses. After years of discussions centered around more universal coverage, our health plan now covers 20 acupuncture visits for all employees regardless of diagnosis. This translates to roughly 47,000 people across Texas now having acupuncture benefits 3. We have enveloped acupuncture into our health plan and are positioning it alongside other medical modalities. In doing so, patients are shifting away from using it as a last resort and are instead relying on it as front-line treatment for pain and other conditions. This is a huge advancement for our hospital network, but it is not an isolated occurrence. Approximately 75% of insurance payers offer some level of acupuncture coverage in the United States, and this number is growing every year.
Future of Program
Four years in, our program is still in its infancy and therefore continuously taking shape. As we establish ourselves, we are also exploring our growth potential and aim to stretch our services into other areas of our hospital system. We would like integrative medicine to expand into the inpatient arena to reduce pain medication usage and enhance patient satisfaction. We also dream of having a small TCM pharmacy so that patients can leave with herbal formulas in hand, especially for acute conditions. Ultimately, we would like to see integrative medicine become an established service line in more of our specialty clinics and hospitals.
Conclusion
Developing and sustaining an integrative medicine department within a hospital system is a challenging yet exciting step for the future of healthcare. By creating a platform in which Traditional Chinese Medicine and western medicine compliment and complete each other, we endeavor to fill the gaps in the healthcare system. This, we believe, is the goal of integration – to offer a comprehensive strategy for health that aligns various medical systems for the benefit of our patients and the advancement of modern healthcare as a whole.
References
- About Baylor Scott & White. Baylor Scott & White Health Web Site. https://www.bswhealth.com/about. Accessed March 13, 2019.
- Ananth S. 2010 Complementary and Alternative Medicine Survey of Hospitals Summary of Results. 2011: 3. http://www.samueliinstitute.org/File%20Library/Our%20Research/OHE/CAM_Survey_2010_oct6.pdf. Accessed March 13, 2019.
- Cowen, V. and Cyr, V. (2015). Complementary and alternative medicine in US medical schools. Advances in Medical Education and Practice, pp.113-117.
